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Identifying and treating “super-utilizers”

24th January 2017

In this Feb. 19, 2016, photo, physician assistant Brett Feldman listens to a patient during a check-up at a shelter in Easton, Pa. Feldman, 34, is one of the nation’s few practitioners of “street medicine,” a tiny health care niche that advocates predict will become more mainstream as hospitals and health care systems seek to cut costs, in part by reducing emergency-room visits among the homeless. (AP Photo/Matt Slocum)

Ray Cavanaugh

Ray Cavanaugh is a freelance writer from Boston, MA. His interests include history, health topics, and current events in faraway places.

Five percent of Medicaid patients account for almost half of the program’s spending, according to a May 2015 report from the U.S. Government Accountability Office.

And the top one percent of patients account for more than 20 percent of healthcare costs, according to the Agency for Healthcare Research and Quality.

Gaining traction in the US is the term, “super-utilizers,” which refers to a small section of the population that accounts for a large portion of emergency room visits and puts a heavy burden on hospital services and public health budgets. The term reached a significant audience by way of a 2011 Atul Gawande article for The New Yorker, which profiled the work of New Jersey doctor Jeffrey Brenner, who identified super-utilizer hotspots in a way akin to how police identify crime hotspots.

These types of patients can be especially challenging because they’re often dealing with homelessness, addiction, and mental illness. Owing to these issues, they frequently bounce from emergency rooms to shelters to jails.

Super-utilizers have existed for decades, but only in the last few years is the issue starting to be addressed in a coordinated way, as hospitals, insurers, philanthropic foundations, and lawmakers in different parts of the country realize that something has to be done about a population of patients who amass astonishingly disproportionate costs to the system and yet continually fail to get the care they need.

There is currently no comprehensive fixed criteria for what constitutes a super-utilizer. Some groups, such as the Centers for Medicare and Medicaid Services, mention “individuals with 4 or more visits per year,” but there are patients who make far, far more visits than that. Some, in fact, can accumulate more than 100 annual ER visits, and cases can be found which considerably exceed even that amount.

Some visit the ER to get a warm, safe place to sleep and a few adequate meals. Staying in a hospital isn’t most people’s idea of a fun time, but for someone who is homeless, a hospital stay can seem like an enticing alternative to a night on the streets (particularly when it’s cold) or in a homeless shelter, many of which can be chaotic and dangerous.

In a $250,000 pilot program that launched in late 2015, the University of Illinois Hospital & Health Sciences System tried an approach that might seem radical to some: give super-utilizers free housing. Twenty-five such patients are currently receiving $1,000 per month for housing, which is more cost-effective than having them accumulate $3,000 daily bills in hospital ERs.

Another possible solution is having specialized community paramedics deal with super-utilizers so they don’t make as many ER trips. Such paramedics go beyond their conventional role of emergency response and provide outreach care to patients who otherwise would call 911 for transport to the ER. One community paramedic program in Minnesota, for example, has already seen super-utilizer ER use decline by 60-70 percent.

Community paramedicine programs are surfacing in both urban and rural settings around the country. California, for example, has 13 community paramedicine pilot projects underway in a dozen locations, according to the state’s Emergency Medical Services Authority. California’s community paramedics are also identifying the most frequent 911 callers and connecting them with the type of services—be they medical or social—that can lower numerous ongoing ER visits.

Along with frequent emergency room visits, super-utilizers often enter the criminal justice system and are incarcerated with dangerous offenders instead of receiving treatment for chronic mental illness or substance abuse issues.

In an effort to divert nonviolent super-utilizers away from prisons and place them in venues where they could receive more appropriate care, the Illinois Criminal Justice and Informational Authority has worked with the Illinois Hospital Association to keep track of super-utilizers by creating a super-utilizer data bank, which would enable authorities to know when they come into contact with a super-utilizer.

Super-utilizers tend to “end up in jail or prison because local law enforcement have arrested them multiple times for low-level offenses like disturbing the peace or retail theft,” says John Maki, executive director of the Illinois Criminal Justice Information Authority. “We’ve heard from law enforcement that they will end up arresting and taking them to jail because they feel as if they have no other way to respond to them.”

“Correctional facilities are often by design severe places, governed by strict rules and procedures,” Maki points out. “If you are suffering from a mental illness, you will likely struggle in this kind of environment. The symptoms of your mental illness will likely lead you to act out in ways that will lead to further punishment, the end of which is typically disciplinary segregation.”

“When criminal justice and health systems work together in ways to identify and direct super-utilizers into community-based services, they can produce much better outcomes for this population,” says Maki. “For instance, crisis stabilization centers provide law enforcement with a much more effective alternative for people they encounter with serious mental illness than jails or emergency rooms.”

Through the creation of data banks, community paramedicine, and experiments with free housing, more providers in the US are getting serious about striving to meet the needs of super-utilizers while lowering costs to the system.

To read the GAO Report,"A Small Share of Enrollees Consistently Accounted for a Large Share of Expenditures", click here.